What services are we able to bill for under MaineCare?
Billable services for school districts are:
- Speech Therapy
- Occupational Therapy
- Physical Therapy
- Rehabilitative and Community Support Services
- Children’s Behavioral Health Day Treatment Services
- Neurobehavioral Status Exam, Neuropsychological Testing and Psychological Testing
How will we identify our Medicaid population?
EDMS will, on behalf of our clients, identify and verify Medicaid eligible children, in your district, prior to billing for services. We continue to recommend that service records be kept for all children receiving IEP ordered services as a matter of best practice. Singling out Medicaid eligible children by identifying eligibility puts families and practitioners in a difficult position in the school setting. By using Lumea™, children receiving services are documented equally and practitioners can continue to focus on effectively serving all children regardless of their eligibility for Medicaid.
The rules state that the services for which we bill must be “medically necessary.” What does that mean?
Pursuant to the MaineCare Benefits Manual, Medical Necessity or Medically Necessary services are those reasonably necessary medical and remedial services that are:
|MCBM Definition of Medical Necessity
|provided in an appropriate setting;
|The regulations define this, and schools meet all definitions of “setting.”
|recognized as standard medical care, based on national standards for best practices and safe, effective, quality care;
|State Practice Acts are based on national standards. Practitioners in the school setting operate within their practice acts.
|required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health
|Special education related services are for the treatment of a disability and improve well‐being.
|MaineCare covered services (subject to age, eligibility, and coverage restrictions as specified
in other Sections of this manual as well as Early and Periodic Screening, Diagnosis and Treatment Services requirements as detailed in Chapter II, Section 94 of this Manual);
|By definition, the services that schools deliver are deemed “covered services” per each applicable section of the MaineCare Benefits Manual.
|performed by enrolled providers within their scope of licensure and/or certification; and
|By definition, schools must utilize properly licensed staff.
|provided within the regulations of the Manual.
|Schools that follow the mandates of the regulations from a documentation perspective should have no difficulty with medical necessity.
Those services listed in an IEP, which meet all other requirements of Medicaid coverage and the MCBM definition of “Medical Necessity,” satisfy the medical necessity requirement except in those instances where the ordered services are deemed Non‐Covered Services by Medicaid.
According to Chapter I of the MaineCare Benefits Manual; Section 1.06-5.B.3: Non‐covered services are those “services that are primarily custodial care, respite care, socialization, academic, religious, vocational, or educational . . . .” The Section goes even further in defining Academic/Educational Services in Section 1.06-5.B.3.c: “Any services or components of services provided to members that are academic or educational in nature. Academic services include, but are not limited to, those traditional subjects such as science, history, literature, foreign languages, and mathematics.”
Is the requirement for “medical necessity” new?
No. Medicaid has always required “medical necessity.”
Can the IEP be used to determine medical necessity?
Yes, so long as all of the requirements of the definition of medical necessity are met. While the IEP plays a key role in Medicaid reimbursement, the evaluation and assessment data done prior to completing the IEP also contain much supporting evidence of medical necessity.
Are signatures required for Service Delivery Records?
Yes. Each session of service delivery must have a signature. In Lumea, electronic signatures are applied to every session when the practitioner “posts” the session.
How are electronic signatures authorized by the service provider?
DHHS has approved the use of the EDMS Electronic Signature Verification Form available in Lumea. This form should be completed annually and kept on file.
Will I have to produce service records for audit purposes?
Are the EDMS Snapshots the only documents I need to refer to for policy and regulations?
No. We create the snapshots for a quick reference. However, the snapshot is not a substitute for a thorough reading and understanding of the appropriate sections of the MaineCare Benefits Manual.
Do we still need parent consent to bill Medicaid?
Is a child’s life time cap affected if the school district bills Medicaid?
We understand that there are no lifetime caps in MaineCare for services delivered to children. Relative to Katie Beckett children, however, our understanding is that caps may be impacted in regards to continuing eligibility under the Katie Beckett option.
Should our district bill for a MaineCare student who has private health insurance?
If a parent grants consent to a school district to bill Medicaid and MaineCare reimburses the school, the consent also allows MaineCare to bill any other private health insurance that covers the child. MaineCare services may be submitted to the parents’ private health insurance, and appear on the private health insurance Explanation of Benefits (EOB). It is unlikely, however, that the child’s private health insurance will reimburse MaineCare for services provided pursuant to a child’s IEP. We do encourage districts to bill for MaineCare eligible students who may also have private health insurance (unless they are Katie Beckett students) as there should be no effect on the family’s private insurance.
How are “written progress notes” documented?
Lumea provides not only a drop down menu for progress notes, but also a text field for a narrative.
May a school district bill for contracted service providers?
Yes. A February 2012 clarification from MaineCare verified that districts may bill for contracted staff as well as employees. A “Statement of Reassignment” form should also be executed with contracted staff who are also enrolled MaineCare providers. See below for further clarification.
Things to Watch for:
Are school districts responsible for checking the OIG List of Excluded Individuals/Entities (LEIE) as well as other exclusions lists?
Yes. The Office of Inspector General (OIG) has the authority to exclude individuals and entities from federally funded health care programs [Medicaid, etc.], and maintains a list of all currently excluded individuals and entities on the LEIE. Anyone who hires and/or contracts with [and directly or indirectly seeks reimbursement for] an excluded individual or entity on the LEIE may be subject to civil monetary penalties, should reimbursement occur to or on behalf of the excluded individual or entity.
Districts should also be aware that the Program Integrity Unit from the Maine Department of Health and Human Services has advised all MaineCare providers that they should also be checking the State of Maine Excluded providers Database as well as the Federal System for Award Management database**. As a Medicaid provider, the school district is mandated to check the LEIE list for the names of all employees and contracted staff for whose services the district is seeking Medicaid reimbursement. The Centers for Medicare and Medicaid (CMS) strongly recommends that this list be checked on a monthly basis. EDMS will, at no charge to the district, assist with this process on behalf of the districts we serve. School districts are responsible for checking the additional exclusions lists.
What is the “Statement of Reassignment” form?
Medicaid has a general prohibition against Medicaid providers reassigning payment for services. For example, if an Occupational Therapist is enrolled as a Medicaid provider, that OT cannot reassign payment for her services to another party. However, there are exceptions to the Prohibition rule in which case Medicaid payments may be made to 1) the employer of the individual practitioner; or 2) the facility in which the service is provided by the contracted practitioner. For this reason, the school district, as a Medicaid provider, may seek reimbursement on behalf of its employed and contracted staff without violating the Reassignment prohibition as long as the individual practitioner has “reassigned” his/her payment to the school district. Best practice would suggest that in the instance where the employee or contracted staff member is also a Medicaid provider, there would be a signed form that states that the employee/contracted staff member has reassigned his/her payment for services to the district and he/she will not seek reimbursement for those same services. While not specifically mandated by state law, the use of the “Agreement of Reassignment” form will allow the district to demonstrate that it took steps to ensure that there would be no duplication of claims by two Medicaid providers. EDMS has provided a form for this purpose.
Should I have a signed “Statement of Reassignment” form for all employed and contracted staff?
No, just the staff members who are themselves enrolled as independent Medicaid providers. Remember, the purpose here is to ensure that there is no duplication of claims being submitted to Medicaid.